Provider Demographics
NPI:1538827662
Name:TIPPENS, NOLAN BLAKE (RBT)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:BLAKE
Last Name:TIPPENS
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:NOLAN
Other - Middle Name:B
Other - Last Name:TIPPENS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RBT
Mailing Address - Street 1:905 PARK AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-4244
Mailing Address - Country:US
Mailing Address - Phone:423-715-7717
Mailing Address - Fax:
Practice Address - Street 1:440 STUART RD NE STE 2
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4959
Practice Address - Country:US
Practice Address - Phone:423-715-7717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN106500000XOtherACORN HEALTH